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4 APPLICATION FOR SANITATION PERMIT Permit No.�r�__`J __ (Complete in Duplicate) e Date Issued Application-is Hereby made to the San Joaquin Local Health District for a permit to construct and install the work herein described. This application is made in compliance with County Ordinancehi 549. - JOB ADDRESS AND OCATION--,)A- -----a4ov f -c .d - Owner's Name4 �' --------------------------- -----,E.--` /i- ,-- E '" , l --- ---- Address --- Address---------------e�_ '_---- t•- -`----- - - -------------------------------------- Contractor's ----- ----------- Contractor's Name------------- -1- ___________ Phone____-__-________________--.-- ----------------------------------- --------------------------------------------------- ------ Installation will serve: ResidenceApartment House E] Commercial E] Trailer Court E] Motel E] Other ❑ Number of living units: _____J Number of bedrooms __ /"Number of baths ---L Lot size ----1 4_x_-41_?_________________________ Water Supply: Public system ❑ Community system '❑ Private xDepth to Water Table,JO ft. Character of soil to a depth of 3 feet: Sand E] Gravel E] Sandy Loam ❑ Clay LoaClay [ Adobe ❑ Hardpan E] Previous Application Made: Yes ❑ No q New Construction: Yes No ❑ p ..:TYPE}OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permi44if public sewer is available within--200-feet:)–� .�....�.— Septic Tank: Distance from nearest well___ Distenfrom foundation � _-_____ No. of compartments_,________ -" ___t_-:Size----c Capacity_ _ __Liquid depth------------ -____ ____ ___.Ot-- -___ } Disposal Field: Distance from nearest well__5-_-------Distance from foundation------- __?J_ Distance to nearest lot line _ --__J-Q--_____ Number of lines--------------- 0- Length of each line-------- of trench___ ___-________-_-_ __ Type of filter material-__-_��'�__.,FDepth of filter material__-__I_ `------.---Total length----------------11,20-- -__-_-___-- Seepage Pit: Distance to nearest well----------------------Distance from foundation------------------- Distance to nearest lot line_______________-. ❑ Number of Pits______________________Lining materia l-----------------------Size: Diameter----•--•---- ------ Depth-------------------------------- Cesspool: Distance from nearest well-----------------Distance from foundation______________ Lining material---------------------._____-______... [� Size: Diameter--------------------------------------Depth----------------------------------------------------Liquid Capacity----------------------------gals. I Privy: Distance from nearest well-------------- __ ___________------------------bistance from nearest"6uilding__ _____:__ ____________________-. ❑ Distance to nearest to line - - i �i. :w:�--- y;; ------------- 1 l�°�'-------,�'Y r Remodeling and/or repairing (describe):_ _ _fly-�-e�_�.-'s5_`.�.-- -.:'tlt%1t1�C--��--------,�-�c,.��----- - ------------a� -�"'�-�'�°°'r--'�'�--------�•�'4�--`-�"+�`.ID" - �,.._-� ------ -----------------------------------------------------------------------------------•----------•------------------------------------------------------------------------------------------------------------------------------ 1 hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County g ordinances, State laws,And rules and regulations ofAi San Joaquin Local Health District, >��(Signed) ---------4` '" " + "'` '"` "---------------------------------------(Owner and/or Contractor) 1 - _�= - – By (Title)----------------------------------------------- .(Plot ------------ .(Plot plan, showing size of lot, location of system in relation to wells, buildings, etc., can be placed on reverse side). FOR ARTMENT USE ONLY i APPLICATION ACCEPTED BY------------- ---- ---------------------------------- DATE-----------.- ` ---- ----------------------------- REVIEWED BY------------------------------------------ c`� ------ DATE-----&-7�------------ -- BUILDINGPERMIT ISSUED------------------------------------------------------------------------------------------------------ DATE=------------------------------------------------------------- Alterations and/or recommendations---------------------------------------------------------------------------------------------------------------------------------------------------------------- ----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- A.– __________________ ______•_••_•_____-_-________________________--- _--- ------------------------------------------------------------------------------------------------------------------------------------------- ------------------------------------------------------------------------------_-------------------------- J FINAL INSPECTION BY-------------- -- 4 Date- - � - SAN JOAQUIN LOCAL HEALTH DISTRICT I 130 South American Street 300 West Oak Street 132 Sycamore Street 814 North "C" Street Stockton, California Lodi, California Manteca, California Tracy, California ES-9-2M 9-51 Revised W-2100 :�' —